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November 10, 1999

Appropriate Use of Child Car Seats

Author Affiliations

Margaret A.WinkerMD, Deputy EditorIndividualAuthorPhil B.FontanarosaMD, Interim CoeditorIndividualAuthorStephenLurieMD, PhDIndividualAuthor

JAMA. 1999;282(18):1721. doi:10-1001/pubs.JAMA-ISSN-0098-7484-282-18-jbk1110

To the Editor: Drs Winston and Durbin1 have given the medical community an excellent overview of the importance of proper restraint of children in motor vehicles. This is a complex issue, however, and some points need further clarification.

It is important to face very young children rearward, not because of weak neck musculature, but because of incomplete ossification of their vertebrae and their lax connecting ligaments. In a severe crash, forward motion of the head when the shoulders are held back can generate enough force on the neck to pull these flexible elements apart, leaving the spinal cord as the last link.2 Even minor stretching of the spinal cord can result in rupture and paralysis, while complete spinal cord separation and death can also occur.3 Readiness to face forward cannot be determined from physical examination, but too often health care professionals give parents poor advice based on inappropriate criteria of muscle strength and head control. Although documented cases of serious neck-tension injuries among forward-facing children are rare, there are none among rear-facing children.4 It is therefore prudent to keep children rear-facing as long as possible, but at least until they weigh 9 kg and are 1 year old, because it is such an easy preventive measure and the consequences of not doing so may be severe.